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Does childhood sexual abuse put one at risk for the onset of bulimia nervosa?

Emily Davies

May 4, 2010


†††††† In recent years, growing observation has drawn link between bulimia nervosa and childhood sexual abuse. The debate over whether the association is just a casual, coincidental relationship or has a cause and effect relationship is one that needs greater assessment. Experiencing childhood sexual abuse may put one at risk for developing bulimia nervosa or lead to psychological problems that are risk factors for bulimia nervosa. Discovering the validity to this hypothesis would help professionals in the medical field better treat victims of childhood sexual abuse and develop appropriate strategies for treating individuals with bulimia nervosa. In addition, it would increase what little is already known about the etiology of bulimia nervosa and what psychological factors go in to the disease.

†††††† The psychology of persons with bulimia nervosa is goes hand in hand to that of persons who have experienced sexual abuse. Some scholars propose that since sexual abuse has put the victim in a situation in which they had no control over, they revert to bulimia nervosa behavior in order to regain their sense of control over their body. In contrast to this theory, it can be concluded that neither of the two are related because data of bulimic and non-bulimic patients does not differ significantly.

Prospective studies

†††††† Due to the expense, amount of time and committed participation of individuals, prospective studies are difficult to come by. To my knowledge, no prospective study has been conducted that followed a victims of sexual abuse to see the rate at which they developed bulimia nervosa.† In this study, a cohort of children would be collected and followed. The presence of sexual abuse and the occurrence of bulimia would be recorded. The data of sexually abused with and without bulimia would be compared to those not abused, with or without bulimia. This would be the ideal study determine if events of sexual abuse cause the onset of bulimia nervosa. In addition to the complications that this type of study has, data would not be reliable unless it was a very large cohort study, consisting of hundred of individuals. This is because not all the individuals are guaranteed to develop bulimia nervosa. Following such a large number of children would also contribute many other variables to the data, including other psychological illnesses.

†††††† A study such as this would provide substantial evidence in determining whether childhood sexual abuse led to the onset of bulimia nervosa, however, one has never successfully been carried out or published.

†††††† Case Control Studies

†††††† Different from a prospective study, a retrospective controlled study would determine data of those who have been sexually abused that developed bulimia by examining the presence of the risk factor in both patients with and without bulimia. In a particular study, conducted in 1993, subjects who had recovered from bulimia nervosa were asked if they had experienced childhood sexual abuse. It was found that of the 80 women with bulimia nervosa that participated, reported higher prevalence of childhood sexual abuse (Rorty, Yager, and Rossotto). This shows that there is a link between childhood sexual abuse and bulimia, but does not prove that sexual abuse could be a valid risk factor since only 28.8% of the patients had reported sexual abuse in their childhood. Also, this study did not focus on sexual abuse, but psychological and physical abuse in childhood as well. Those types of abuse were reported in 20.0% and 17.5%, respectively. Rorty, Yager, and Rossotto concluded that since the values were close in range signifies sexual abuse as a risk factor does not stand out from other risk factors of bulimia nervosa.

†††††† In another retrospective controlled study, Pope et. al (1994), conducted a study of 91 bulimic women, representing three different countries, who were asked to report if they experienced sexual abuse. In this study, it was found that 32% of the women had been sexually abused before the onset on bulimia. Pope et. al, concluded that if sexual abuse did exist as a risk factor, then there would a higher percentage of it in patients with bulimia nervosa (1994).

†††††† Though these are relevant studies, childhood sexual abuse could have been proven a risk factor with stronger evidence had the cohort been sexual abuse instead of the bulimia nervosa. However, even then one would not be able to identify whether sexual abuse put a victim at risk for bulimia since so many outside factors are involved and there is so much time between abuse and the onset of bulimia in most patients.

Uncontrolled Studies

†††††† Oppenheimer et al. conducted an uncontrolled study in which 79 women with eating disorders were asked to fill out a questionnaire and participate in a verbal interview; it was discovered that 67% of the bulimic patients reported sexually abuse in their history (1985). This strongly supports that sexual abuse could be a risk factor for the onset of bulimia nervosa. However, Lacey interviewed 112 women who met the criteria for bulimia nervosa and discovered that only 7% of them reported having childhood sexual abuse (1990). Lacey argued that since such a negligible percentage of patients reports sexual abuse, one of whom reported it after the onset of bulimia nervosa, it was unlikely that sexual abuse was the risk factor in these patients (1990).

Methodological Considerations

†††††† The ideal study in determining if childhood sexual abuse is a risk factor for bulimia nervosa would a longitudinal prospective study. However, as previously mentioned, orchestrating one is extremely difficult and risky to do. Three things that would greatly improve the studies mentioned in this review would be: a) blind assessment, b) defining the definition of sexual abuse, and c) recording the time between sexual abuse and onset of bulimia. In a blind assessment, participants could be asked of their history of sexual abuse, regardless of bulimia nervosa. Then, the same people would be diagnosed as bulimic or not. This would better distinguish the direct relationship of sexual abuse to bulimia, if present. Defining sexual abuse would also help ensure that all data is relevant and precise. For example, patients would not be reporting experiences of sexual abuse of differing severities (reoccurring, single incident, etc.). Noting the number of years between sexual abuse and the patientsí onset of bulimia nervosa would provide more data that justified sexual abuse as a risk factor or not. The less amount of time present between the two would limit the number of outside factors and help validate the hypothesis.


†††††† It is near impossible to determine whether a previous experience could catalyze psychological characteristics that could put one at risk for bulimia nervosa. There are so many individual differences regarding psychological coping mechanisms to sexual abuse that the line could not be immediately drawn to bulimia nervosa. Furthermore, since there is a lack in elevated rates of childhood sexual abuse in bulimic compared to that in healthy patients, the hypothesis that it is a risk factor cannot be supported.



Harrison G. Pope, Jr., M.D., Barbara Mangweth, M.A., Andre Brooking Negrao, †††† M.D.,† James I.Hudson, M.D., and Taki Athanassios †††††††† Cordas, M.D. (1994). Childhood sexual abuse and bulimia nervosa: a comparison of American, Austrian, and Brazilian women. Am J Psychiatry 151(5): 732.


Marcia Rorty, Ph.D., Joel Yager, M.D., & Elizabeth Rossotto, M.A. (1994). Childhood ††††† Sexual, Physical, and Phychological Abuse in †††††††† Bulimia Nervosa. Am J Psychiatry, 151(8): 1122-1126.


Harrison G. Pope, Jr., M.D., & Jame I. Hudson, M.D. (1992). Is Childhood Sexual Abuse a Risk Factor for Bulimia Nervosa. Am J ††††††† Psychiatry, 149(4): 455-462.


Oppenheimer R, Howells K, Palmer RL, Chaloner DA. (1985). Adverse sexual experience in childhood and clinical eating disorders: a †††† preliminary description. Am J Psychiatry Res, 19:357-361.


Lacey JH: Incest, incestuous fantasy, and indecency: a clinical catchment-area study of normal-weight bulimic women. (1990). Br J †††††††† Psychiatry, 157:399-403.



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